Defining utility and predicting outcome of cadaveric lower extremity bypass grafts in patients with critical limb ischemia.
Defining utility and predicting outcome of cadaveric lower extremity bypass grafts in patients with critical limb ischemia.
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定义尸体下肢旁路移植术在严重肢体缺血患者中的效用并预测结果。
DOI：
10.1016/j.jvs.2014.06.009
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发表时间：
2014
影响因子：
4.3
通讯作者：
Berceli,ScottA
中科院分区：
文献类型：
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作者：
Chang,CatherineK;Scali,SalvatoreT;Feezor,RobertJ;Beck,AdamW;Waterman,AlysonL;Huber,ThomasS;Berceli,ScottA
目的尽管长期通畅性差，但各种适应症的深低温保存大隐静脉搭桥术(CVB)保肢效果良好。然而，CVB在严重肢体缺血(CLI)患者中的应用仍不确定。该分析的目的是确定CVB在CLI患者中的作用，并确定预测成功结果的因素。方法对单一机构的所有下肢旁路手术进行回顾，并对CLI患者的CVB进行进一步分析。主要终点是无截肢生存。次要终点包括初级通畅和保肢。使用寿命表来估计终点的出现。结果2000~2012年间，1059例患者接受了各种适应症的LEB治疗，其中81例因缺血性静息痛或组织丢失而接受CVB治疗。平均年龄(±标准差)为66岁±10岁(男性，51%；糖尿病，51%；血液透析依赖，12%)，73%(n=59)有同侧LEB或血管内介入治疗失败的病史。没有一个拥有足够的自体管道，甚至可以进行复合静脉搭桥。完成腹股沟下CVB(网下靶点，96%；n=78)的多个适应症，包括Rutherford分级4级(42%；n=34)，5级(40%；n=32)，6级(18%；n=15)。11例(14%)合并CLI并移植物感染(n=8)或急性慢性缺血(n=3)。术中辅助物(如腹股沟深部成形术、腹股沟上支架或旁路)的成功率为49%(n=40)。并发症发生率为36%(n=29)，30d死亡率为4%(n=3)。CLI患者的中位随访期为11.8(四分位数范围，0.4-28.4)个月，相应的1年和3年精算估计生存率(±标准差平均值)分别为84%±4%和62%±6%。CVB治疗CLI 1年和3年的原发通畅率分别为27%和17%±6%。1年和3年的无截肢存活率分别为43%±6%和23%±6%，静息疼痛组(59%±9%，36%±10%)明显高于组织丢失组(31%±7%，14%±7%；LOG，P=0.04)。CLI组术后1年和3年的截肢成功率分别为57%±6%和43%±7%。CVB CLI队列保肢的多变量预测因素包括术后华法林(危险比[HR]，0.4；95%可信区间[CI]，0.2-0.8)、血脂异常(HR，0.4；95%CI，0.2-0.9)和休息疼痛(HR，0.4；95%CI，0.2-0.9)。主要截肢的预测因素包括移植物感染(HR，3.1；95%CI，1.1-9.0)。结论在没有自体管道和腹股沟下搭桥失败的CLI患者中，CVB的结果令人失望。CVB在有休息疼痛的患者中表现最好，特别是那些可以用华法林抗凝的患者。然而，在有轻微组织丢失或并发移植物感染的患者中，这可能是一种可接受的选择，但考虑到潜在的成本影响，应该考虑到非血运重建的CLI和非生物管道替代的已知自然病史。
ObjectiveDespite poor long-term patency, acceptable limb salvage has been reported with cryopreserved saphenous vein bypass (CVB) for various indications. However, utility of CVB in patients with critical limb ischemia (CLI) remains undefined. The purpose of this analysis was to determine the role of CVB in CLI patients and to identify predictors of successful outcomes.MethodsA retrospective review of all lower extremity bypass (LEB) procedures at a single institution was completed, and CVB in CLI patients were further analyzed. The primary end point was amputation-free survival. Secondary end points included primary patency and limb salvage. Life tables were used to estimate occurrence of end points. Cox regression analysis was used to determine predictors of limb salvage.ResultsFrom 2000 to 2012, 1059 patients underwent LEB for various indications, of whom 81 received CVB for either ischemic rest pain or tissue loss. Mean age (±standard deviation) was 66 ± 10 years (male, 51%; diabetes, 51%; hemodialysis dependence, 12%), and 73% (n = 59) had history of failed ipsilateral LEB or endovascular intervention. None had sufficient autogenous conduit for even composite vein bypass. Infrainguinal CVB (infrapopliteal target, 96%; n = 78) was completed for multiple indications including Rutherford class 4 (42%; n = 34), class 5 (40%; n = 32), and class 6 (18%; n = 15). Eleven (14%) had CLI and concomitant graft infection (n = 8) or acute on chronic ischemia (n = 3). Intraoperative adjuncts (eg, profundaplasty, suprainguinal stent or bypass) were completed in 49% (n = 40) of cases. Complications occurred in 36% (n = 29), with 30-day mortality of 4% (n = 3). Median follow-up for CLI patients was 11.8 (interquartile range, 0.4-28.4) months with corresponding 1- and 3-year actuarial estimated survival (±standard error mean) of 84% ± 4% and 62% ± 6%. Primary patency of CVB for CLI was 27% ± 6% and 17% ± 6% at 1 and 3 years, respectively. Amputation-free survival was 43% ± 6% and 23% ± 6% at 1 and 3 years, respectively, and significantly higher for rest pain (59% ± 9%, 36% ± 10%) compared with tissue loss (31% ± 7%, 14% ± 7%; log-rank,P= .04). Freedom from major amputation after CVB for CLI was 57% ± 6% and 43% ± 7% at 1 and 3 years. Multivariable predictors of limb salvage for the CVB CLI cohort included postoperative warfarin (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.2-0.8), dyslipidemia (HR, 0.4; 95% CI, 0.2-0.9), and rest pain (HR, 0.4; 95% CI, 0.2-0.9). Predictors of major amputation included graft infection (HR, 3.1; 95% CI, 1.1-9.0).ConclusionsIn CLI patients with no autologous conduit and prior failed infrainguinal bypass, CVB outcomes are disappointing. CVB performs best in patients with rest pain, particularly those who can be anticoagulated with warfarin. However, it may be an acceptable option in patients with minor tissue loss or concurrent graft infection, but consideration should be weighed against the known natural history of nonrevascularized CLI and nonbiologic conduit alternatives, given potential cost implications.